Treatment rates for the pox in early modern England: a comparative estimate of the prevalence of syphilis in the city of Chester and its rural vicinity in the 1770s

This article offers an innovative attempt to construct an empirically-based estimate of the extent of syphilis prevailing in two contrasting populations in late eighteenth-century Britain. Thanks to the co-incident survival of both a detailed admissions register for Chester Infirmary and a pioneering census of the city of Chester in 1774 taken by Dr John Haygarth, it is possible to produce age-specific estimates of the extent to which adults of each sex had been treated for the pox by age 35. These estimates can be produced both for the resident population of Chester city and comparatively for the rural region immediately surrounding Chester. These are the first estimates of the prevalence of this important disease produced for the eighteenth century and they can be compared with similar figures for England and Wales c. 1911–1912.

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Treatment rates for the pox in early modern England: a comparative estimate of the prevalence of syphilis in the city of Chester and its rural vicinity in the 1770s

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Treatment rates for the pox in early modern England: a comparative estimate of the prevalence of syphilis in the city of Chester and its rural vicinity in the 1770s

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ENDNOTES

1 The historic term ‘venereal disease’ will be used throughout, though of course the correct terms used today are STD (sexually-transmitted disease) and STI (sexually-transmitted infection).

2Wrigley, E. A. and Schofield, R. S., The population history of England 1541–1871: a reconstruction (London, 1981); Wrigley, E. A., Davies, R. S., Oeppen, J. E. and Schofield, R. S., English population history from family reconstitution 1580–1837 (Cambridge, 1997); Woods, R., The demography of Victorian England and Wales (Cambridge, 2000); Laslett, P., Family life and illicit love (Cambridge, 1977); Peter Laslett did very briefly discuss venereal disease in n. 6 on p. 221 of the bastardy volume he co-edited in 1980; and T. C Smout offered a slightly longer discussion on Scotland in the same volume, pp. 194–7: Laslett, P., Oosterveen, K. and Smith, R. M. eds., Bastardy and its comparative history (Cambridge, MA, 1980).

3McKeown, T., The modern rise of population (London, 1976), 60–3. Syphilis is not addressed in Anne Hardy's The epidemic streets: infectious disease and the rise of preventive medicine 1856–1900 (Oxford, 1993). While Peter Baldwin provided an informative comparative study of government medical policy and discourse regarding syphilis, he did not critically address the question of incidence when reproducing contemporary summary estimates; see Baldwin, P., Contagion and the state in Europe 1830–1930 (Cambridge, 1999), 425.

4Landers, J., Death and the metropolis: studies in the demographic history of London 1670–1830 (Cambridge, 1993); Dobson, M., Contours of death and disease in early modern England (Cambridge, 1997).

9Szreter, S., ‘The prevalence of syphilis in England and Wales on the eve of the Great War: re-visiting the estimates of the Royal Commission on Venereal Diseases 1913–1916’, Social History of Medicine27, 3 (2014), 508–29.

14 The original volumes of Chester Infirmary's (CI) Journal of patients are held by Cheshire Archives and Local Studies in Chester. The best available account of the Chester Infirmary's early history (it only acquired the ‘Royal’ in its current title in 1914) is contained in the relevant section of the Victoria county history (VCH): Barrow, J. S., Herson, J. D., Lawes, A. H., Riden, P. J. and Seaborne, M. V. J., ‘Local government and public services: medical services’, in Thacker, A. T. and Lewis, C. P. eds., A history of the county of Chester, Volume V, Part II: the City of Chester: culture, buildings, institutions (London, 2005), 49–58, http://www.british-history.ac.uk/vch/ches/vol5/pt2/pp.49-58 [accessed 16 January 2016].

15 Like all voluntary hospitals in the eighteenth century, the Chester Infirmary was funded by voluntary subscription from among the more substantial citizens of the city and, indeed, of the general vicinity (many subscribers resided in towns all across Cheshire and North Wales – see endnote 82). Subscribers had the right to recommend patients for treatment, which would generally be offered gratis. This meant that many patients appearing at the hospital would have first needed to approach a subscriber for a recommendation, though this would not have been an unusual form of behaviour in a relatively paternalistic and hierarchical culture and community such as Georgian Chester and its rural hinterland. It was also the case that patients might present themselves directly to one of the doctors at the Infirmary.

16 On Haygarth, see his Oxford Dictionary of National Biography entry, www.oxforddnb.com/index/12/101012766/; and Booth, C., John Haygarth, FRS (1740–1827): a physician of the enlightenment (Philadelphia, 2005).

17 The numbers of venereal cases admitted each of these three years: 65 in 1773; 58 in 1774; and 54 in 1775.

18 Chester city in 1774 comprised six parishes ‘within the Walls’: St Michael's, St Olave's, St Bridget's, St Martin's, St Peter's, and Cathedral; and four outer parishes: St Mary's, St Oswald's, St John's, and Trinity. Cathedral parish is sometimes referred to in documents (including in the CI Journal) as ‘St Werburgh’ parish. This is a reference to the name of the pre-Reformation Abbey, which was reconstituted as Chester's cathedral of Christ and St Mary in 1541 by Henry VIII. To confuse things further in 1799 a new St Werburgh's church was built in Chester and this is the Roman Catholic parish church (within the Catholic diocese of Shrewsbury). VCH: Baggs, A. P., Kettle, Ann J., Lander, S. J., Thacker, A. T. and Wardle, David, ‘Chester Cathedral’, in Elrington, C. R. and Harris, B. E. eds., A history of the county of Chester, Volume III (London, 1980), 188–95, http://www.british-history.ac.uk/vch/ches/vol3/pp188-195 [accessed 23 February 2016].

19 Chester, with its castle, had traditionally been a barracks town but the military presence by this decade was nominal.

20 The process of medical diagnosis of all diseases, including the venereal diseases, has of course a rich and diverse early modern history, as much cultural as medical, as much lay as scientific, as historians such as Stein and Stolberg have shown: Stein, Negotiating the pox; Stolberg, M., Uroscopy in early modern Europe (Routledge, 2015), following the earlier lead of Porter, Roy ed., Patients and practitioners: lay perceptions of medicine in pre-industrial society (Cambridge, 1985).

21 Among those infected with gonorrhoea about 70 per cent of women and 55 per cent of men are asymptomatic; see McFalls, J. A. and McFalls, M. H., Disease and fertility (New York, 1984), 262–4.

22Flegel, K. M., ‘Changing concepts of the nosology of gonorrhoea and syphilis’, Bulletin of the History of Medicine48, 4 (1974), 571–88, here 576–84.

23 These were vaginal discharges, which were at that time considered to be either symptoms of the milder disease of gonorrhoea (‘clap’) or due to a solely female ailment; see Churchill, Wendy D., Female patients in early modern Britain (Farnham, 2012), 149–50; Risse, Guenter B., New medical challenges during the Scottish Enlightenment (Amsterdam, 2005), 294–5.

25Risse, G., Hospital life in Enlightenment Scotland: care and teaching at the Royal Infirmary of Edinburgh (Cambridge, 1986), 126.

26Haygarth, John, A clinical history of diseases: part first: being 1. A clinical history of the acute rheumatism. 2. A clinical history of the nodosity of the joints (London, 1805), 91.

27 Bynum, ‘Treating the wages of sin’, 16.

28 Boswell also visited Chester in 1779 and apparently recorded a detailed journal, which he claimed was ‘a log book of felicity’. Sadly, as his modern editors record, ‘One would very much like to read a journal of Boswell's so characterised, but it is unfortunately and unaccountably missing- the only major journal of his now unaccounted for.’ Reed, J. W. and Pottle, F. W. eds., Boswell: Laird of Auchinleck 1778–1782 (New York, 1977), 139.

29 There are also four cases visible where a venereal patient was first treated only as an outpatient for a period but subsequently returned to be admitted as an inpatient, staying for more than 35 days on that second occasion: John Jones (age 27, St Mary's parish); Elizabeth Pritchard (age 27, St Oswald's Parish); Elizabeth Williams (age 33, St Oswald's parish); and Jane Williamson (age 20, St Oswald's parish). There are modest age discrepancies in each of these patients’ two records, but it seems most likely on examining all the evidence in the two entries that they were in each case the same individual.

30 Bynum, ‘Treating the wages of sin’, cites from the contemporary authority Andree, John, Observations on the theory and cure of the venereal disease (London, 1779), v: ‘the method practiced in hospitals of salivating for the cure of most venereal disorders, cannot be adopted in private, as very few patients would submit to so severe a mercurial course, unless for the cure of the worst state of the disease.’

31 These patterns of duration before discharge for venereal diagnoses are confirmed by calculations both from entries in the CI Journal and separately from those in the Register of the significantly larger number of admissions for St Thomas's, London during the years 1769–1771. I am grateful to Kevin Siena for making available his research materials on St Thomas's.

32 Thomas Leighton of St John's parish was the only individual appearing twice as a venereal inpatient and was treated for at least 35 days on both occasions during these three years (though it is just possible this was two different people as he is listed as age 40 on admission in May 1773 and 44 in October 1773). For the purposes of subsequent analysis Leighton has been treated as a single individual, although his case does not contribute, below, to the calculation of age-specific rates of infection, as he was over 34 years of age. Three of the four married couples had the same surname, parish of residence and were admitted on the same day (Bowden, Cooke and Leighton), a fourth probable couple were admitted three months apart (Burgess) and a fifth we can be less certain of because though from the same parish, they were admitted three months apart and bore the common surname of Jones.

33Haygarth, J., ‘Observations on the population and diseases of Chester in the year 1774’, Philosophical Transactions of the Royal Society68 (1778), 131–54, Table V.

34 The authors of the VCH question whether Haygarth may have over-counted somewhat, by including some families in the suburbs, which were outside the boundary of Chester in 1774. See text at notes 19 and 20 in VCH: J. S. Barrow et al., ‘Economic infrastructure and institutions: population’, in Thacker and Lewis eds., A History of the County of Chester, Volume V, Part II, 71–3, http://www.british-history.ac.uk/vch/ches/vol5/pt2/pp71-73 [accessed 19 January 2016]. They specifically point out that Haygarth counted 4,027 inhabitants in St Oswald's parish in 1774, but there were only 3,377 enumerated there in 1801. But they also acknowledge, as is well known, that the 1801 census itself had many defects. There is, additionally, the distinct possibility that population genuinely did decline between the two dates in this parish, which was considered overcrowded and unhealthy in 1774 by Haygarth. Furthermore, against the VCH suggestion, it is inconsistent with internal evidence in Haygarth's original text to suppose that he would have carelessly or accidentally counted a considerable number from outside the boundary, since at one point he demonstrates that he was fully aware of the importance of relating correctly geographically-defined numerators to denominators. Thus, he records that he had investigated the issue of whether the central parishes of Chester might appear to be more healthy because ‘more who die in the city may be buried in the suburbs than the contrary’ and also ‘that a reason why the whole town appears so healthy, [could be] that more persons who die in it may be buried in the country than the contrary’. His conclusion regarding these matters is reported as follows, ‘but on strict enquiry I can find no foundation for either supposition. The extent of the survey both in each parish, and in the town in general, corresponds with much exactness with the extent of the register.’ Reference to ‘the extent of the register’ meant the territory covered by the registers of baptisms, burials and marriages of each of the city's parishes; see Haygarth ‘Observations’, 137. However, it is also to be acknowledged that the VCH suggestion of an over-count in 1774 appears to be supported by Wrigley's recent set of estimates for the period 1761–1801. Wrigley's estimate for the population of Chester c. 1774 would be approximately 13,720 (the average of his two figures for Chester 1771 and 1781 in his Table A2.7), a figure that is 6.75 per cent lower than Haygarth's count of 14,713. Wrigley's estimation method is to use a combination of back-projection from the age structure in 1801 along with what are believed to be the least inaccurate demographic data-series for English parishes from this period, which relate to parish returns of marriage ceremonies conducted after Hardwicke's Act of 1753. See Wrigley, E. A., The early English censuses (Oxford, 2011), 112–15; and see also Wrigley, E. A., ‘English county populations in the later eighteenth century’, Economic History Review60, 1 (2007), 35–69. However, it must be acknowledged that this method becomes less reliable the further back in time it is applied before 1801 and that it is particularly vulnerable to inaccuracy where a population is known to have experienced considerable amounts of gender-specific in- and out-migration at the typical marriageable ages of the period, a feature that was characteristic of Chester city at this time and which is taken into account in Tables 6A and 6B. Marriages not recorded in the Anglican parish registers constitute another possible source of inaccuracy for this method (see endnotes 40–2). Overall, given what we know of Haygarth's meticulousness and alertness to the boundary issues, I am inclined to accept Haygarth's contemporary count in 1774 as a basically accurate one, which would also incidentally imply that the city grew more evenly across the three decades of the 1760s, 1770s and 1780s than is implied by Wrigley's estimation procedure, which suggests much more modest growth in the 1770s than in either the 1760s or 1780s.

35Coale, A. J. and Demeny, P., Regional model life tables and stable populations (Princeton, 1966). A second edition was published in 1983 by Academic Press (authored by Coale, Demeny and B. Vaughan), which provides greater detail for survivorship rates for ages above 80. This does not materially alter the estimates presented here, which use the figures published in the first edition, as also used in 1997 by Wrigley et al., English population. Note that there are several other model life table schemes in use today of varying degrees of mathematical sophistication, such as the UN, WHO, Lederman, and Brass Logit Systems. See the unpublished and also undated online working paper: C. L. Murray et al., WHO system of model life tables, GPE Discussion Paper Series, 8 (WHO), http://www.who.int/healthinfo/paper08.pdf. I am grateful to Ian Timaeus for advice on the use here of the Coale and Demeny model life tables.

36 Wrigley et al., English population, 261–3, 535–6, which also notes that Model North may be a less useful guide before the mid-eighteenth century.

37 The figures are to be found in the following three publications: Haygarth, J., ‘Observations on the Bill of Mortality in Chester for the year 1772’, Philosophical Transactions of the Royal Society64 (1774), 67–78, Tables I, III; Haygarth, J., ‘Bill of Mortality for Chester for the year 1773’, Philosophical Transactions of the Royal Society65 (1775), 85–90, Tables I, III; Haygarth ‘Observations … in the year 1774’ (1778), Tables I, VI.

38Hesketh, T. and Xing, Z. W., ‘Abnormal sex ratios in human populations: causes and consequences’, Proceedings of the National Academy of Sciences103, 36 (2006), 13271–5. They state a norm of 105.9:100 as the overall average of the ratio that has been found to occur ‘naturally’, that is, under conditions where no known attempts are made to alter the ratio and where all births are recorded accurately.

39 Model North Level 7 gives an infant mortality rate of 219.0 per thousand for males and 187.7 per thousand for females. The weighted average of these two rates, allowing for a ratio of 104 males born to 100 females, as recorded by Haygarth, being 203.66 per thousand. It is also possible to draw on a wider range of contemporaneous data provided by Haygarth in his various publications. He later published data for six consecutive years centred on 1774, 1772–1777 inclusive, which gives information on all deaths under age 1. This records a total of 483 infant deaths, an average of 80.5 deaths per annum. He also published information on the number of christenings per annum during the sequence of 11 years, 1764–1774, which can be calculated at 399 per annum. From this combined data, the resulting estimated infant mortality rate of 201.8 per thousand births again tallies extremely closely with the average for 1772–1774.

Haygarth, J., A sketch of a plan to exterminate the casual smallpox (London, 1793), 141.

40 Wrigley and Schofield's examination of the phenomenon afflicting Anglican parish registers of both non-registration by non-conformists and under-registration of births by lax Anglicans among their national sample of 404 registers found only a very slight problem of under-registration in the 1770s, which is therefore not considered here; but they did find a more substantial problem of nonconformist non-registration amounting to the need for a 15 per cent correction factor (The population history, Appendix 4, Table A4.1). However, this was of course a problem that is primarily proportional to the relative size of the nonconformist community. In Chester the latter amounted to about 3.63 per cent of the population only.

46 The subsequent 1851 census cannot be used as it only published age distribution information on Registration Districts and sub-districts. From 1837 until 1869 the population of the city of Chester fell within the much larger Registration District of Great Boughton. Unfortunately the city's population was divided between two of Great Boughton's registration sub-districts, Chester Castle and Chester Cathedral, each of which included about half of the city's population along also with an extensive population from the surrounding rural area in each case. http://www.cheshirebmd.org.uk/subdists.php

47 The 1821 census was the first time such an exercise was attempted – on a far from fully literate or fully numerate populace. Its results are known to be less secure in this respect than those of 1841 and subsequent censuses. Nationally about 12.5 per cent of the enumerated population at the 1821 census lacked an age record. The London returns were considered particularly deficient, while the attempt to obtain ages for the Manchester population was judged a complete failure. In relation to Chester the census authorities printed a cautionary note stating that ‘The total number of Enumeration Returns from the county of Chester was 504, two of which contained no answer to the question concerning Ages of persons … And a small proportion of the Returns of Ages were somewhat deficient or redundant – or incorrect in the respective numbers of Males and Females.’ 1821 Census, Observations, enumeration and parish register abstracts, 1821, 36.

48 The somewhat lower proportion of the population above age 70 at the later date would in fact be predicted if the town was principally growing by net immigration between ages 15–24 at both dates (rather than by significant changes between the two dates in overall mortality or fertility) and if its overall growth rate was significantly faster in the first half of the nineteenth century than it had been in the second half of the eighteenth century, as was, indeed the case.

49 The only broadly comparable city for which any detailed evaluation can be made of the difference between its mortality level in the late eighteenth and mid-nineteenth centuries is Carlisle. In the 1780s, Carlisle's life expectancy was probably above that of Chester's in the 1770s and conformed to Model North Level 9, a slightly higher level of salubrity as would be expected for a city only half the size of Chester at that time. However, by the period 1838–1853, Carlisle's mortality conditions have been shown to have deteriorated to just below Level 7 (overall e0 of 33 years). It is unlikely that Chester's mortality had deteriorated in the same way over these decades, since Carlisle's problems were attributable to its partial-industrialisation and associated tripling in population size with attendant overcrowding problems. Chester's growth over this period was much more gradual (only just over a 50 per cent rise in population size) and it remained a non-industrial city (see text immediately following). For details on Carlisle, see Szreter, S., Health and wealth: studies in history and policy (New York, 2005), 181–2.

50 The difference that cannot be accounted for by mortality effects is then negligible in the subsequent two age groups, 35–9 and 40–9, but somewhat greater again above ages 50.

51 Thus, the numbers of males enumerated at ages 10–14, 15–19, 20–4 and 25–9 in 1841 bear exactly the relationship to each other of gradual successive decline in numbers that would be predicted by application of the survival formulae of Model North Level 8. This suggests that any inflows and outflows of young adult males in Chester in 1841 were quite closely matching each other quantitatively at all age ranges. Whereas the numbers of females enumerated do not decline at all, as would normally occur due to accumulating mortality effects, but instead rise from 1257 at ages 10–14 to 1317 at ages 15–19 and 1401 at ages 20–4, before rapidly declining back to 1,095 at ages 25–9 and 930 at ages 30–4. At age 30–4 there were only 135 more females than males in Chester (an excess of 17 per cent), whereas there were 395 more at ages 20–4 (an excess of fully 39.26 per cent). Note, additionally, that this does not mean that numbers of males may not also have been moving in and out of Chester, nor does it mean that no females left Chester – we know that British society was highly mobile both in the first half of the nineteenth century but also in the second half of the eighteenth century. Thus, the 1841 census records that in fact only 7,483 of Chester's 10,728 male inhabitants were born in the county of Chester and only 8,611 females of its 12,387 females. It simply means that the preponderance was for the flow of female immigration at young adult ages, 15–24, to swamp all other movements; and also that female out-migration in their late twenties and early thirties was a second predominating pattern, at least in the decade or two prior to the 1841 census. Logically, there is also the possibility that this pattern could have been produced by a radical earlier change in migration patterns: if there had been almost no net female in-migration to Chester at ages 15–24 in the decade of the 1820s, unlike the pattern in the 1830s. This seems impossible, however, given that a marked sex imbalance favouring females was a constant feature of the city's population found both in 1774 and confirmed at each successive census from 1801 onwards.

52VCH: ‘Late Georgian and Victorian Chester 1762–1914: Social character’, in Thacker, A. T. and Lewis, C. P. eds., A History of the County of Chester, Volume V, Part I: the City of Chester: general history and topography (London, 2003), 199–201, http://www.british-history.ac.uk/vch/ches/vol5/pt1/pp199-201 [accessed 9 January 2016].

53 Census 1831, Enumeration Abstract (Part I), 69.

54 Joyce Ellis has pointed out that Chester was rather like the similar northern cathedral city of York, in that these two cities, regional capitals that had for centuries stood second in the nation's urban hierarchy after London, were simply not closely associated with the regional industrialising developments that overtook and transformed the social complexion of so many other towns and parishes in their regions: J. Ellis, ‘Regional and county centres’, in P. Clark ed., Cambridge urban history, ch. 20, 673–704, here 675.

55 According to Wrigley's new estimates across the four decades 1761–1801, Chester's population grew overall by 35.7 per cent, reaching 15,970; see Wrigley, Early English censuses, Table A2.7. Over the next four decades its population certainly grew somewhat faster but not in the hectic manner of so many other towns of comparable size directly affected by the arrival of manufacturing, such as Macclesfield in the east of the county or, for instance, Carlisle, further north. Chester reached a total of over 23,000 by 1841, such that its overall growth over those next 4 decades after 1801 was 47 per cent (for comparison, the urban population as a whole experienced 100 per cent growth in Britain between 1801 and 1841).

56 Although there was no apparent net male out-migration at these ages from Chester recorded at the 1841 census, the 1821 census does indicate a significant degree of net male emigration from the city at these ages. While the 1841 census has been preferred as the most reliable general guide because of known inaccuracies with age reporting in the 1821 census, this aspect of the 1821 results has been considered of some relevance. The judgment made here has been to include a moderate degree of net male emigration from Chester in the 1774 model.

57 Note that in order to achieve this comparability and to maintain correspondence with what we know of the biology of syphilis, the denominator at each successive quinquennial age group has been reduced by the number of cases in the numerator at the previous age group, since without modern effective treatments that entirely exterminate the spirochaete from the body, once an individual has been infected by syphilis they are no longer at risk of a subsequent separate attack (though of course they remain at risk of subsequently developing the potentially fatal consequences of tertiary syphilis many years later precisely because the T. pallidum bacteria remain in the body).

58 It can be seen that the overall chance of requiring treatment for the pox at the CI for females at these ages is actually slightly higher than for males. However, taking into account all ages up to age 64 (the oldest case in the admissions registers for 1773–1775 was 60 years old) the chances were in fact somewhat higher for males because there was a strong preponderance of male cases at ages 35–64 (7:2). The focus here is exclusively on rates up to age 35, in order to achieve comparability with the research completed on the population of England and Wales in 1911–1912.

60 As Siena has found to be extensively the case by this time in London: Siena, Venereal disease, ch. 4.

61VCH: J .S. Barrow, et al., ‘Local government and public services: medical services’, 49–58, notes 80 and 81. The Chester House of Industry located on the Roodee was constructed in 1757, just two years after the opening of Chester's subscription Infirmary.

62 In fact two were admitted in 1774, one in 1773, none in 1775. We have no information on the average size or age or sex characteristics of the residents of the Chester House of Industry during these years and so it is not possible to evaluate what proportion these three cases may have represented to the numbers found among the prime ‘at risk’ population (those ages 15–34) residing in the House of Industry.

63 Siena, Venereal disease, chs. 3–4.

64Siena, Kevin, ‘The “foul disease” and privacy: the effects of venereal disease and patient demand on the medical marketplace in early modern London’, Bulletin of the History of Medicine75, 2 (2001), 199–224.

66Porter, Roy, ‘Lay medical knowledge in the eighteenth century’, Medical History29, 2 (1985), 138–68. The Appendix to this article reproduces a facsimile from the Gentleman's Magazine in 1748, which prints a list of comparative prices for ‘Nostrums and Empirics’ from about 100 different retailers in London. This shows medicines for pox or impotence regularly cost a good deal more (5–10 shillings) than most other prescriptions for coughs, colds, the ‘itch’ or ‘pain’, etc. (mostly priced at 1–3.5 shillings). Medicine for ‘gleets’ (symptoms of a milder venereal disease – probably gonorrhoea or chlamydia) fell in between at 3.5– 5 shillings. Ten shillings (half a pound) represented about half a good weekly wage for London manual labourers and much more than half in lower-wage Cheshire.

67 Booth, John Haygarth, 152: ‘Tantalizingly, there was no mention in [Haygarth's] will of the doctor's papers, nor of the case records he had so carefully amassed during his Chester years. They have simply disappeared.’ The only superficially comparable surviving source from the region I have come across is: The medical casebook of William Brownrigg of Whitehaven MD, FRS (1712–1800) (Medical History Supplement no. 13 1993). The editors warn however that this source records a deliberately selective, not a statistically complete or representative sample, of just 127 cases. Consequently no conclusions can be drawn about either the social complexion of patients consulting Brownrigg nor the conditions they presented.

68 The decision to apply an average rate of infection to the Chester social elite reflects the likelihood that some individuals within that elite held attitudes and engaged in behaviour that was more likely than average to result in their contracting the pox, while others were of the opposite disposition. The only robust evidence of this point relates to the male social elite of England and Wales in 1911–1912, where official data indicated that males of Registrar-General's Social Class I were somewhat more likely than average to have contracted the disease. However, this later data relates to males only at a date when postponement of marriage among males of this class was at a historic peak. The judgement here relates to the consideration of both sexes combined in Chester in the 1770s and it is considered in view of this, that the imputation of an average rate of infection to the Chester social elite, taken as a whole, is the best working assumption.

70 For more details, see O'Gorman, F., ‘The General Election of 1784 in Chester’, Journal of the Chester Archeological Society57 (1970–1), 41–50; Sweet, R., ‘Freemen and independence in English borough politics c. 1770–1830’, Past and Present161 (1998), 84–115.

71An alphabetical list of the names, places of abode and occupations of all the freemen of the city of Chester who polled (and for whom) at the late election (printed by J. Fletcher: Chester 1784). There was, of course, no secret ballot at this time – hence all votes are recorded. The residence criterion made recording of the voter's address a relevant matter, while the recording of occupation reflected the fact that acquisition of the status of borough freeman had historical roots in guild and trade membership through serving an appropriate apprenticeship. Being born the son of a freeman or serving an apprenticeship were still the two principal ways of acquiring freeman voting rights in Chester in 1784 for both parliamentary and local elections; while a third possibility was that the Chester Assembly (the city's governing body) had the power to create a freeman by order. http://archivedatabases.cheshire.gov.uk/cms/lacfreemenofchester/home.aspx

72 Sweet, ‘Freemen and independence’, 99–101.

73 As the VCH reports, ‘At its most effective the Grosvenor political machine was vigilant for every opportunity to influence voters in Chester, and willing to spend heavily: perhaps £4,000 a year between elections and far more during them. In 1784 the Grosvenors spent £24,000 in all, of which £15,000 went on drink and £1,600 on yellow ribbons and cockades.’ VCH: ‘Late Georgian and Victorian Chester 1762–1914: politics, 1762–1835’, in Lewis and Thacker eds., A history of the county of Chester, Volume V, Part I, 154–60, http://www.british-history.ac.uk/vch/ches/vol5/pt1/pp154-160 [accessed 9 January 2016].

74 O'Gorman, ‘The general election’, 46–7, notes that the Grosvenor family campaign was ‘well organised … thoroughly conducted’ and he cites, for instance, from a document monitoring the numbers of votes cast on each of the 11 consecutive days of the contest for each candidate, held in the Grosvenor archive.

75 The VCH mentions a likely electorate of 1,500 freemen in 1821 but there do not appear to be securely known figures for the late eighteenth century. With just over 1,100 voting in 1784, O'Gorman considers this to have been in practice close to a full turnout: ‘Given the shifting and mobile electorates of the day it was hardly possible for more than 1200 voters to have come to the polls from an electorate of this size.’ O'Gorman, ‘The general election’, 48. The VCH also cites O'Gorman's research that in all contested parliamentary elections from 1784 until 1825, ‘The Grosvenor candidates were favoured by more of both the wealthiest freemen (gentlemen, professionals, merchants, and industrialists) and the poorest (unskilled and semiskilled labourers), whereas retailers and craftsmen were on the whole more likely to back the Independents.’ VCH: ‘Late Georgian and Victorian Chester 1762–1914: politics, 1762–1835’, 154–60, http://www.british-history.ac.uk/vch/ches/vol5/pt1/pp154-160 [accessed 20 January 2016].

76 In counting individuals from the Chester polling list as genteel, I have used both O'Gorman's helpful detailed listing of various titles to be classed as his Class I, ‘Gentlemen and Professionals’; but also augmented by Mitchell's advice (see next note) on which among O'Gorman's Class II, ‘Merchants and Manufacturers’, should also be included for the particular purposes of this exercise. O'Gorman, F., Voters, patrons and parties: the unreformed electoral system of Hanoverian England 1734–1832 (Oxford, 1989), Appendix 1, 394–9.

77 Thus, those listed on the record of the 1784 poll as grocer (but not the more modest ‘victualler’), draper, mercer, hatter, goldsmith/silversmith or watchmaker and wine merchant (but not indiscriminate ‘merchants’) have also been counted among the genteel, along with cabinet-makers (but not ‘upholsterers’), printers, booksellers and inn-keepers/inn-holders (but not ‘publicans’). Although this will include a few grocers, cabinet-makers and inn-keepers who may not in fact have been genteel, their inclusion will compensate for one or two of the genteel who have been missed either by excluding from the ranks of the genteel all other occupational designations (such as possibly some of the individuals listed as ‘boat-builder’, ‘coachmaker’, ‘clothier’ or ‘tobacconist’) or because they did not in fact vote (though the poll remained open for 11 days from 5 until 16 April, giving ample opportunity to cast a vote). Mitchell, S. I., ‘Retailing in eighteenth and early nineteenth-century Cheshire’, Transactions of the Historic Society of Lancashire and Cheshire130 (1981), 37–60, 38, 48–9.

78 Of the 1,118 individuals listed, six were indeterminate, owing to absence of both occupational and useable status information (such as ‘esquire or ‘gent’). In an earlier analysis of this source, Frank O'Gorman stated that there were 1,102 voters who cast a total of 1,857 votes counted among the four candidates. However, the alphabetical printed list gives 1,118 separate names with their residence and trade. The total number of votes is recorded as 1,857, as O'Gorman states. With two votes per voter, the reason for the large shortfall (from a potential total of 2,236) is that many voters only gave a single vote for one candidate (usually those voting for the Independent, Mr Crewe).

79Barfoot, P. and Wilkes, J., The universal British directory (London, 1792), 703, cited in F. O'Gorman, Voters, patrons and parties, 208. O'Gorman also gives somewhat diverse estimates of the proportion of Chester's male electorate falling within his Class I of ‘Gentlemen and Professionals’, offering a set of three figures of about 9.5 per cent for the early nineteenth century (his Tables 4.12 and 4.13), but figures of 17 per cent and 25 per cent in 1747 and 1784, respectively (his Table 4.14). In his accompanying text (p. 207), O'Gorman seems to play down these discrepancies, emphasising instead the overall averaged finding from his evidence for both Chester and other similar ‘Large freeman’ electorates that about 13.6 per cent of the electorate was comprised from Class I. The count produced here of 211 ‘genteel’ voters (18.9 per cent of the turnout) represents 14.1 per cent of the notional electorate (if the consensus figure for Chester of about 1,500 is correct).

80 Most freemen of Chester either inherited their right to the franchise through their father at age 21 or obtained the right through entry into one of the City's trade companies after completion of apprenticeship, which would also typically occur about age 21. The adjusted North Level 7 life table presented in Table 6A indicates that these 211 genteel voters would have represented approximately 5.29 per cent of the male population of 3,992 aged 21 and above in 1774.

81 According to Haygarth's 1774 census there were 3,428 separate families residing in Chester's ten parishes, of which about two thirds (2,611) lived in the four less salubrious outer parishes of St Mary's, St John's, St Oswald's and Trinity. Therefore 183 genteel, married householders represent heads of approximately 22.4 per cent of the balance of the 817 families living in the six more desirable inner parishes.

82 With its generally sparse and rural settlement pattern Wales was the region most poorly provided with qualified medical practitioners in Britain at this time: Digby, A., Making a medical living: doctors and patients in the English market for medicine, 1720–1911 (Cambridge, 1994), 20. The invaluable third edition of 1783 of Simmons's Medical register listed a total of just 125 medical practitioners in Wales. See Simmons, S. F., The medical register for the year of 1783 (London, 1783). This represents a population ratio of 1 per 4,332 relative to the numbers enumerated at the first decennial census of 1801. For reference, Anne Digby has estimated from this source that provincial England in 1783 enjoyed a ratio almost exactly twice as favourable, with 1 practitioner per 2,224. Within these two Welsh counties of Flintshire and Denbighshire, the towns of Denbigh, Wrexham, Hawarden, St Asaph, Bangor, Ruthin, Llanrwit (Llanrwst), Holywell and Mold had 17 of Wales's total of 125 registered practitioners between them, though the latter seven had only one each. Joan Lane in her 1984 article, which first drew attention to the importance of the third edition of Simmons's Medical register, states the number of practitioners in Wales at 129, which seems to be a slight over-count of the names listed by Simmons under the Welsh counties. See Lane, Joan, ‘The medical practitioners of provincial England in 1783’, Medical History28 (1984), 353–71, here 354.

83 Cheshire is described in Capper's, Benjamin PittsA topographical dictionary of the UK (London, 1808) as having one city and twelve market towns: Altrincham, Congleton, Frodsham, Halton, Knutsford, Macclesfield, Malpas, Middlewich, Nantwich, Northwich, Sandbach and Stockport.

86Razzell, Peter, The conquest of smallpox: the impact of inoculation on smallpox mortality in eighteenth-century Britain (Firle, Sussex, 1977), 146.

87 Simmons's Register lists 40 named practitioners working in Cheshire, in addition to the 17 resident in Chester city: Altrincham (1), Congleton (6), Frodsham (1), Knutsford (5) Macclesfield (5), Malpas (2), Middlewich (3), Nantwich (6), Neston (1), Northwich (2), Sandbach (1), Stockport (4), Tarpaly (1), Upton (1), Wilmslow (1). In general there were relatively few university-educated physicians outside London and there were only five listed by Simmons’ Register in Cheshire, three of whom resided in Chester and were attached to the CI (the two others practised in Nantwich and in Macclesfield, respectively). There were only eight in the whole of Wales, only one of whom was in either Denbighshire or Flintshire (listed in Wrexham).

88 From a total of 40 non-Chester venereal patients who remained in the hospital more than 21 days (and so presumably were at least suspected on entry of harbouring the pox), 21 came from within the county of Cheshire, 11 of whom came from towns with medical practitioners: Nantwich (2), Frodsham, Malpas, Congleton, Northwich (3), Stockport, Neston and Tarpaly. Note that Congleton was fully 28 miles from Chester and Stockport, located in the far east of the county, was 34 miles distant. This indicates that the CI's capacity to offer the resource-intensive residential care necessary to (supposedly) cure cases confirmed as the pox, was widely known and valued, particularly given that it was offered free to the patient.

89 One patient listed as residing in ‘Salop’ may be such a case; there were no more than three others: Abergele (30 miles away); ‘Wallon’ (probably Walton or Wharton, either of which was 17–18 miles to the east); and ‘Llanayn’, a Welsh village which cannot be identified and has been assumed to be further than ten miles from Chester.

90 They were recorded as residents of the following parishes (with distance and direction from Chester given in brackets): Gresford (eight miles south); Little and Great Sutton (six miles north); two from Hawarden (six miles west); Christleton (two-and-a-half miles east); Tarvin (five miles east); Frodsham (ten miles north-east); Neston (ten miles north-west); Hope (eight miles south-west); Harthill (nine miles south); Bunbury (ten miles south-east); Tarporley (nine miles east); Backford (four miles north); Newton (one mile north-east); and Skewiog (a hamlet of Northop, ten miles west).

91 Wrigley, Early English censuses, Table A2.7 and p. 114. It is not necessarily inconsistent to gratefully draw upon the results of Wrigley's estimation procedures for the populations of these rural Hundreds of west Cheshire, while setting it aside, above (note 34), in relation to the city of Chester, in favour of the direct observational evidence of Haygarth's census. Firstly, there is no such direct observational alternative available for the Hundreds before 1801; and secondly, the populations of these rural Hundreds were less subject than Chester city to the effects of proportionately large sex-differential migration on the proportions of their adults of marriageable age, a factor which is crucial to Wrigley's methodology and, which, it was argued above, may render it less robust for an urban population such as Chester's.

92 Holt was at this time under the diocese of Chester, transferring to St Asaph in 1849.

93 A circle with radius ten miles has an area of 314.2 square miles. This has been reduced by the five square-mile area with the city of Chester at its centre and allowing ten square miles each for the two small stretches of the Mersey and Dee estuaries on either side of the southern end of the Wirrall peninsula, which fall within a ten-mile radius from the centre of Chester. The 1831 census recorded 3,010 acres for Chester city, equivalent to 4.7 square miles (the city's boundaries had not changed since 1774: the liberties of Chester, at 3,000 acres, were first demarcated in 1354).

94 Frodsham's population totalled 1,250 in 1801; Neston's 1,486; Mold was larger at 4,325 in 1801, but is outside the ten-mile radius.

95 Contrary perhaps to expectations, this adjustment factor reflects the likelihood that these parishes’ populations had in fact been larger in 1775 than they were by 1801. Their 1801 totals were each inflated by the same ratio by which the population of Broxton – the nearest Hundred of Cheshire neighbouring Wales – was found by Wrigley to be greater in population size c. 1774 than it had been in 1801. Although Wrigley shows Chester city itself growing by about 15 per cent between c. 1774 and 1801, the encompassing westernmost division of Cheshire, Broxton Hundred, contracted overall by a little over 10 per cent; while its eastern neighbour in Cheshire, Eddisbury Hundred, experienced little if any net growth; and furthermore Wirrall Hundred, to the north, is shown as contracting by as much as 50 per cent. By contrast all of Cheshire's four eastern Hundreds grew significantly by 20–50 per cent, particularly Bucklow (on the Mersey) and Macclesfield, but also Northwich and Nantwich in the south of the county. Wrigley, Early English censuses, Table 4.4, 114, Table A2.7.

97 It only first becomes possible to compare reliably the likely scale of the age and sex structure differences of the enumerated populations of young adults of Chester City and the western Cheshire Hundreds of Broxton, Wirrall and Eddisbury in the Report from the 1841 census. However, by this date Wirrall had already begun to grow extremely rapidly (Wrigley, Early English censuses, p. 117) and so it really cannot be considered comparable to the population residing there in the 1770s. However, both rural Broxton and Eddisbury Hundreds in 1841 can be expected to provide some comparability with their positon in relation to Chester city in the 1770s, in terms of possible differences in their age and sex distributions at ages 15–29, the peak ages for migration (and also for risk of contracting syphilis). The 1841 census shows that while in Chester city 28.24 per cent (3,030) of its 10,728 males were ages 15–29, only 24.95 per cent of Eddisbury's males and 25.28 per cent of Broxton's males were ages 15–29. In Chester city 30.78 per cent of its 12,387 females were ages 15–29, as against only 25.91 per cent in Eddisbury Hundred and 27.36 per cent in Broxton. Overall that corresponds to 12.5 per cent more males and 15.5 per cent more females at these ages in Chester city than in these two rural west Cheshire Hundreds. This is an average of 14 per cent. However, the evidence presented here in Tables 3, 4 and 5 indicates that Chester's relative excess of young adults was probably somewhat greater in the 1770s than it was in 1841 and therefore an adjustment of 16 per cent has been adopted in the text. It is likely that the sex differences between urban Chester and rural Cheshire at both dates, in the 1770s and in 1841, were due primarily to net in-migration of females to Chester city and a combination of net out-migration of both males and females from rural Cheshire at these age ranges.

98 All the areas cited have been adjusted to allow for the area of the city of Chester and for the Dee and Mersey estuary areas.

99 Note that the term prevalence has been used throughout to describe the measures produced here and in the previous publication relating to 1911–1912. Strictly speaking the methods used have produced an indicator of the cumulative chance of ever having been infected with syphilis by age 35. In populations lacking effective treatment, this corresponds to the proportion who are at that age infected with the spirochete, Treponema pallidum, due to its continuing presence in their bodies (though most will be in the latency phase of the disease). It is in that sense that the measures constructed here assesses the prevalence of the microorganism among the individuals in the populations studied.

100 Szreter, ‘The prevalence’, 526–8.

101 Siena, Venereal disease. The construction of comparable estimates for London is the subject of ongoing collaborative research by the author with Kevin Siena.